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PSYCHOGERIATRICS 2014; ••: ••–••

doi:10.1111/psyg.12064

CASE REPORT

Anton–Babinski syndrome in an old patient: a case report and
literature review
Jiann-Jy CHEN,1 Hsin-Feng CHANG,2 Yung-Chu HSU3 and Dem-Lion CHEN4

1

Department of Neurology, Neuro-Medical
Scientific Center, Buddhist Tzu Chi General
Hospital, Taichung Branch, 2Faculty of Chinese
Medicine, College of Chinese Medicine, China
Medical University, Taichung, 3Division of
Neurology, Department of Internal Medicine,
Ditmanson Medical Foundation Chia-Yi Christian
Hospital, Chia-Yi, and 4G-Home Clinic, Kaohsiung,
Taiwan
Correspondence: Dr Yung-Chu Hsu MD, Department
of Neurology, Ditmanson Medical Foundation
Chia-Yi Christian Hospital, Chia-Yi City, Taiwan.
no. 539, Chung-Shao Road, Chia-Yi City 60002,
Taiwan. Email: chessergg@gmail.com
Received 4 November 2013; revision received 8 August
2014; accepted 15 August 2014.

Key words: Anton–Babinski syndrome, blind
anosognosia, cortical blindness, occipital lobe
infarction, visual confabulation.

Abstract
Anton–Babinski syndrome is a rare disease featuring bilateral cortical blindness and anosognosia with visual confabulation, but without dementia or
any memory impairment. It has a unique neuropsychiatric presentation and
should be highly suspected in those with odd visual loss and imaging
evidence of occipital lobe injury. In the case discussed herein, a 90-year-old
man presented with bilateral blindness, obvious anosognosia, and vivid
visual confabulation, which he had had for 3 days. Brain computed tomography demonstrated recent hypodense infarctions at the bilateral occipital
lobes. Thus, the patient was diagnosed with Anton–Babinski syndrome.
Because of his age and the thrombolytic therapy during the golden 3 hours
after ischemic stroke, the patient received aspirin therapy rather than tissue
plasminogen activator or warfarin. He gradually realized he was blind during
the following week, but died of pneumonia 1 month later. In the literature, it
is difficult to establish awareness of blindness in patients with Anton–
Babinski syndrome, but optimistically, in one report, a patient was aware of
blindness within 2 weeks, without vision improvement. Our case illustrates
that elderly patients with Anton-Babinski syndrome can partially recover and
that 1 week is the shortest time for the establishment of awareness of
blindness for sufferers without vision improvement.

INTRODUCTION
Acute bilateral blindness is a neuro-ophthalmological
emergency. In consideration of neuropsychiatric conditions in the elderly, it could be attributable to
intracranial lesions (e.g. pituitary or bilateral occipital
lesions),1,2 bilateral optic nerve lesions (e.g. bilateral
anterior ischemic optic neuropathy caused by giant
cell arteritis), and rarely, demyelinating disease or
conversion disorder.3 To reach an exact localization, a
detailed history and physical examinations can never
be overemphasized. If a patient presents blindness
and visual anosognosia, it is very difficult for the firstline physicians to make a correct diagnosis, and many
assume that the condition is psychiatric, especially in
elderly patients.

CASE REPORT
A 90-year-old man with a background of chronic
obstructive pulmonary disease presented with right
© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society

hemiparesis. Brain computed tomography (CT)
showed old lacunar infarctions at the bilateral basal
ganglia (Fig. 1a), and magnetic resonance imaging/
angiography demonstrated an acute lacuna infarction
at the left putamen and focal stenosis at the bilateral
posterior cerebral arteries (Fig. 1b). The patient was
treated conservatively with oral aspirin 100 mg, and
the symptoms abated over the following week. He
was able to lead an independent life and did so over
the course of the following year.
A year later, the patient presented to the emergency
room because had been having frequent falls and had
been unable to grasp anything put in front of him for 3
days. His initial blood pressure was 140/68 mmHg,
and electrocardiography showed atrial fibrillation with
a heart rate of 75 beats per minute. He was alert and
stated that his vision was fine. He had poor eye
contact when interviewed and could recognize his
family only by sounds, but he could obey verbal
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J-J. Chen et al.

Figure 1 (a) Non-contrast brain computed tomography showed old lacunar infarctions at the bilateral basal ganglia. (b) Time-of-flight
magnetic resonance angiography had shown focal stenosis (arrowheads) at the bilateral posterior cerebral arteries one year earlier. (c)
Non-contrast brain computed tomography showed recent symmetric hypodensities in the bilateral occipital lobes (arrows) when Anton–
Babinski syndrome occurred.

orders. His muscle power and sensory function in the
four limbs were full and intact. According to the ophthalmic consultation, the fundus examination was
unremarkable, and the patient’s pupil size and
pupillary reflexes were symmetric and intact. He did
not have ptosis, ocular dysconjugate movement,
excessive blinking, head wounds, or orbital swelling.
Blood examinations all showed normal results. The
frontline physician diagnosed him as presenting with
obvious total blindness with delirium or confabulation.
A neurologist was consulted to evaluate the
patient’s mental status. When a pen was put in front of
him, he claimed that nothing was there. He could not
see the neurologist’s waving hands, and he could not
obey our order to perform any pursuit, saccade, or
optokinetic nystagmus test. Instead of worrying about
blindness, he vividly described surroundings that did
not actually exist. The three-object recall test for
memory was correct. He did not have any sensory
hemineglect. To exclude cortical lesions, non-contrast
brain CT was performed; it demonstrated recent
hypodense lesions at the bilateral occipital lobes
(Fig. 1c).
The patient was diagnosed with Anton–Babinski
syndrome. Cardiac echo did not show significant
abnormalities. Mixed-type (artherosclerotic plus
cardioembolic) ischemic stroke was diagnosed, and
because of his age and the thrombolytic therapy over
2

the golden 3 hours, he received aspirin 100 mg per
day rather than warfarin or tissue-plasminogen activator. After education, he gradually realized that he
was blind over the following week. Occupational
therapy and sensory rehabilitation were recommended. However, dyspnoea gradually became exacerbated, and he could not submit to brain magnetic
resonance imaging/angiography again, single-photon
emission CT, or other neuropsychiatric examination.
The patient died of pneumonia during the following
month.

DISCUSSION
Anton–Babinski syndrome, also known as Anton’s
syndrome, Anton’s symptom, and Anton’s blindness,
was first described by Gabriel Anton in 1899.1 It was
later described as blind anosognosia by Joseph
François Babinski.2 In summary, Anton–Babinski syndrome is a rare neuropsychiatric syndrome featuring
bilateral cortical blindness and anosognosia with
visual confabulation, but without dementia or any
memory impairment.3 Patients behave as if they are
sighted and usually have vivid confabulation. Despite
the intact anterior visual tracts, the bilateral occipital
lobes are damaged. Injury to the visual association
cortex accounts for the disconnection phenomenon,
which explains why patients are unaware of their
blindness. Visual disconnection to language areas
© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society

Anton–Babinski syndrome

causes functioning speech areas to confabulate in
response.3 In our case, Anton–Babinski syndrome
was suspected because of blind anosognosia and
visual confabulation, without dementia or any memory
impairment. Also, CT confirmed new lesions at the
bilateral occipital lobes (Fig. 1c), indicating bilateral
cortical blindness.
In addition to Anton–Babinski syndrome, other
similar neuropsychiatric phenomena should also be
considered when patients present with a similar condition.1 Similar neuropsychiatric phenomena include
the following: akinetopsia, or motion blindness, in
which patients can only see motionless objects
but not moving ones;2,4 Riddoch syndrome, which
manifests as residual motion vision within the
hemianopic field;3,5 Charles Bonnet syndrome, which
involves oriented, poor visual-acuity patients having
complex visual hallucinations;4,6 Balint’s syndrome,
which affects both visual perception, causing simultanagnosia and visual disorientation, and visual control
of eye and hand movement, causing optic ataxia and
ocular apraxia;5 prosopagnosia, a selective visual
agnosia resulting from damage to a cortical network
devoted to the accurate perception of faces;6,7 and
Dide–Botcazo syndrome, an extension of Anton–
Babinski syndrome but with involvement of memory
circuitry,8 similar to the case report of temporary
Anton–Babinski syndrome with amnesia.9 Our patient
did not present with above conditions.
Anton–Babinski syndrome is one of specific form
of cortical blindness. The aetiologies include the
following:1 ischemia stroke or haemorrhage involving
occipital lobes;2,10–15 posterior leukoencephalopathy
induced by chemotherapy,16 radiotherapy,17 preeclampsia,18 adrenoleukodystrophy,19 or mitochondrial
encephalomyopathy, lactic acidosis, and stroke-like

episodes;3,20 obstetric haemorrhage with posterior circulation hypoperfusion;4,21 and trauma-related optic
neuropathy, bifrontal contusions, and callosal disconnection.22,23 Recovery of visual function can be
expected if the underlying factor is posterior reversible leukoencephalopathy or cortical hypoperfusionis,
and it is corrected quickly.18,21 Ischemic stroke is the
most common cause of Anton–Babinski syndrome
and was the cause in our case. There have been only
eight reported cases of stroke causing Anton–
Babinski syndrome in the past 5 years (Table 1). The
patients were aged between 51 to 96 years, and five
patients were men. Only one patient’s vision recovered fully (no. 8),15 and three recovered partially (nos.
1, 2, and 7).10,11,14 The first task in rehabilitating such
patients is establishing awareness of blindness.11,13
However, in the literature, it is difficult to establish
awareness of blindness in patients with Anton–
Babinski syndrome, but optimistically, in one report, a
patient was aware of blindness within 2 weeks,
without vision improvement (no. 4).12 Our patient presented was aware of his blindness within 1 week,
which may be the shortest time for the establishment
of awareness. Early diagnosis of Anton–Babinski syndrome enables early antiplatelet drugs therapy, which
may improve vision or awareness of blindness, even in
the elderly.
Our patient demonstrated two hallmarks of Anton–
Babinski syndrome: bilateral cortical blindness and
anosognosia with visual confabulation. This builds
on the limited literature on Anton–Babinski syndrome
that currently exists. Furthermore, our patient had
suspicious CT imaging both before and while he
had Anton–Babinski syndrome; the syndrome was
attributable to mixed-type (artherosclerotic plus
cardioembolic) infarction due to atrial fibrillation and

Table 1 Case reports of ischemia stroke with ABS, available in the English literature in the past 5 years
Prognosis
No

Age/gender

Ischemic area

Insight

Vision

Author and case details

1
2
3
4
5
6
7
8

83/F
73/M
72/M
55/M
51/M
96/M
56/F
63/F

Right O, left O-P
Bilateral O, bilateral T
Bilateral O
Bilateral O, left P
Right O
Bilateral O
Bilateral O
Bilateral O

No
Not mentioned
Not mentioned
Yes (2 weeks)
No
No
No
Not mentioned

Improved
Improved
Blindness
Blindness
Blindness
Blindness
Improved
Recovered

Maddula et al.10
Case 3 in Gaber11
Case 4 in Gaber11
Kondziella and Frahm-Falkenberg12
Eby et al.13
Carvajal et al.14
Carvajal et al.14
Spiegel et al.15

ABS, Anton–Babinski syndrome; F, female; M, male; O, occipital lobe; P, parietal lobe; T, thalamus.

© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society

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J-J. Chen et al.

bilateral posterior cerebral arteries’ focal stenosis. Our
case’s dyspnoea gradually became exacerbated so
he could not submit to brain magnetic resonance
imaging/angiography, brain blood flow in singlephoton emission CT, or other neuropsychiatric examination, but we observed improved visual awareness
within the first week. Eventually, he died of infection
so long-term follow-up was not possible. We suggest
that early stroke treatment and awareness build-up
are worthwhile for elderly patients with stroke-related
Anton–Babinski syndrome.

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© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society